Part Three
Priorities for public health and
health promotion
9 Social determinants of health
10 The major causes of ill health
11 Lifestyles and behaviours
12 Population groups
Part 1 of this book explored the key drivers for pub­
lic health and health promotion and Part 2 discussed
core strategies. In Part 3, we take an overview of the
current priorities for public health and health pro­
motion. The focus here is on the UK, but many of
these priorities are the same for other developed and
developing countries. Health is created through the
interplay of many factors, including:
• economic status
• the environment
• genetic disposition
• how people behave
• people’s ability to satisfy basic needs
• the quality of people’s social relations
• access to prevention, treatment and
care services.
This gives rise to a broad, and at times bewilder­
ing, array of priorities, encompassing and address­
ing the underlying socio­economic determinants of
health, preventing illness through early detection and
intervention, improving access to effective treatment
and care, reducing the risk factors for ill health and
death (smoking, poor nutrition, inadequate physical
activity and accidental injury), and meeting the needs
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of specific population groups who are seen as vulner­
able or over­represented in ill health statistics.
The history of public health demonstrates a par­
ticular concern with the physical aspects of the envi­
ronment that may influence health directly, such as
water purity and housing quality. Other factors may
influence health indirectly and interact with each
other – poverty, for example, is associated with poor
housing, diet and education. Figure S3.1 illustrates
some of the links between socio­economic circum­
stances and health outcomes, including the ways
in which social attitudes and contexts facilitate or
hinder individual health behaviours and the resources
that promote health.
Public health and health promotion recognizes
that a tension exists between agency and structure –
whether people are autonomous free agents who
choose the behavioural choices that promote or
threaten their health, or a deterministic view that
sees social and environmental factors as shaping
health outcomes. These elements are often seen as
discrete and independent variables to be addressed
separately. Dahlgren and Whitehead’s (1991) dia­
gram, however, shows the health of the population
as affected by interlocking factors: broad, societal or
 Pa r T T h r e e Priorities for public health and health promotion
Figure S3.1 • Socio-economic
circumstances and health outcomes,
Source: acheson (1998)
Social
structure
Social
environment
Early life
Culture
‘upstream’ forces such as poverty and unemployment,
‘midstream’ factors that have a direct influence on
people’s lives and reflect broader social issues such as
living and working conditions, and the individual life­
style or ‘downstream’ factors that are also affected
by the broader conditions in which individuals and
families live their lives.
Different theoretical approaches explore the rela­
tionship between the social environment and health.
Positivist sociologists focus on the impact and con­
straints of social determinants on individual choices,
behaviours and health status. For example, poverty
and a polluted environment will disadvantage people,
lead to ‘poor’ health choices, and impact negatively
on their health. Postmodernists place greater stress
on the cultural meanings and significance of fac­
tors affecting health – for example, risk behaviours
may be positively valued by some groups, leading to
adverse health consequences. Life­course perspec­
tives analyse the ways in which biological risk inter­
acts with economic, social and psychological factors
in the development of chronic diseases throughout
life. A person’s social experience is influenced by
genetic endowment, biology and physiology – for
example, low birth weight is linked to physical and
social disadvantages in later life.
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Material, psychosocial
Work
Psychological Brain
Patho-physiological
changes
Health
behaviour
• Mortality
Genes
• Morbidity
• Well being
The role of individual lifestyles in determin­
ing health status is undisputed, although there are
different theories as to what factors affect lifestyles,
and how lifestyles impact on health. Whilst the
focus is usually on negative effects, the salutogenic
approach seeks to explain the factors responsible for
creating and maintaining good health. In particular,
Antonovsky (1987) focused on how a ‘sense of coher­
ence’ within individuals can explain the relationship
between life stress and health status. The challenge
for public health is being able to identify, promote
and protect the salutogenic factors that promote
health even amongst disadvantaged people.
The medical origins of public health are apparent
in the focus on communicable diseases and chronic
conditions that impact on quality of life and longev­
ity. This is reflected in policies such as the National
Service Frameworks (NSFs) for England and Wales.
NSFs set standards for the provision of high quality
and evidence­based services relating to major diseases
and client groups and also aim to reduce unacceptable
variations in care and treatment. NSFs are intended
to be inclusive and are developed in partnership with
a range of service providers and service users. NSFs
currently exist for the following disease conditions:
cancer, paediatric intensive care, high blood pressure,
 Priorities for public health and health promotion
coronary heart disease, diabetes, mental health, renal
services and long­term conditions. In addition, there
are NSFs for older people and children. The control
of communicable diseases is another priority in public
health, and one that is receiving increased attention
as a result of the worldwide increase in HIV and out­
breaks such as SARS and swine flu.
Public health refers to the health of the whole
population, but within that category, certain groups
of people may be prioritized. The rationale for focus­
ing on specific groups is usually that their health
potential is not being met. This often emerges from
research that demonstrates that a specific population
group has a high level of health needs that are often
unmet due to problems with service access and avail­
ability (e.g. asylum seekers, migrants and travellers).
Targeting can, however, stigmatize groups. HIV, for
example, is concentrated in social groups that are
already marginalized, such as commercial sex work­
ers, injecting drug users and men who have sex with
men. It can also lead to oversimplification in catego­
rizing the targeted group. Black, Asian and minority
ethnic (BAME) groups, for example, are frequently
treated as a homogenous category for interventions.
Interventions to improve health are necessarily
complex and inter­linked. A major emphasis is on life­
styles and behaviour change through education and
awareness­raising programmes. The focus of many
interventions is on defined diseases and is targeted
at changing the behaviours of high­risk individuals.
In recent years, there has also been a shift towards
introducing systemic and structural changes to cre­
ate environments for better health. Public health
and health promotion strategies thus range from the
macro structural level via the meso community level
to the micro individual level. There are numerous
policy initiatives that seek to address the social deter­
minants of health, e.g. housing and transport. The
challenge for many public health and health promo­
tion professionals is how to be involved in the politi­
cal processes and policy making. Adopting the lens
of a social model of health through which to tackle
priorities is also challenging. At the meso community
level, local interventions and projects seek to address
priority areas using local knowledge, resources
Pa r T T h r e e
and skills. For many health and welfare workers,
individual clients remain the focus. Working with
individual clients does not exclude a consideration of
how social determinants impact on their health, or
how their individual behavioural choices result from
community and peer pressures. Whilst it may not be
the immediate focus of practitioner­client contacts,
recognition of the impact of broad structural factors
on individuals can only increase the effectiveness of
work with individual clients.
In practice, public health strategies often use a
mix of interventions spanning all three levels. For
example, food and diet is a public health and health
promotion priority area, and poor diet is responsible
for a great deal of associated ill health and disease.
Food and diet may be construed as an individual
lifestyle choice, and many interventions take this
approach, focusing on education or weight monitor­
ing to try to effect changes in diet. Many people work
with individual clients or patients to raise awareness
of health issues and provide information and counsel­
ling to change knowledge, attitudes and behaviour.
However, research has also pointed out that diet is
related to socio­economic determinants of health,
and therefore a useful focus may be on communi­
ties rather than individuals. Community interven­
tions rely on strategies such as partnership working
and building and releasing community capacity and
capability. Many of the necessary skills and solutions
exist within communities but may require facilitation
and networking in order to materialize. For example,
interventions such as food cooperatives, food gardens
and growing projects and breakfast clubs in schools
all rely on the skills and resources that exist within
communities. Community interventions seek to
model healthier food options and make them acces­
sible and appropriate for local populations. Finally,
many of the factors affecting diet are structural, such
as the loss of local shops due to supermarkets’ aggres­
sive marketing and pricing policies, inadequate food
labelling, and poor dietary choices in workplaces and
schools. These factors require lobbying and advocacy
at local or national levels to tackle relevant struc­
tures. An example of successful lobbying and media
advocacy is Jamie Oliver’s campaign for healthy
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 Pa r T T h r e e Priorities for public health and health promotion
school meals (http://www.channel4.com/life/micro­
sites/J/jamies_school_dinners/, accessed July 2009).
Features of successful and effective interventions at
each level are identified, and evidence showing that
tackling this kind of priority area is effective is col­
lated and presented.
Part 3 therefore explores four public health and
health promotion priorities: the social determinants of
health, the major causes of ill health and mortality,
lifestyles and behaviours, and population groups. Each
chapter first explores the rationale for prioritizing this
category and then goes on to identify how it has been
addressed. Examples are given of work at different
levels – macro (structures), meso (communities) and
micro (individuals). We hope that Part 3 of this book
will prove inspirational in identifying the huge range
References
Acheson D: Independent inquiry into inequalities in
health, London, 1998, The Stationery Office.
Antonovsky A: The salutogenic perspective: towards a new
view of health and illness, Adv J Mind-Body Health
4(1):47–55, 1987.
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of skills, interventions and activities that can impact
positively on public health and health promotion.
Many of these activities are not primarily concerned
with health although they may be pivotal in promot­
ing good health. For example, tackling poverty is a key
government policy area because it is seen as crucial to
creating a more egalitarian, inclusive and democratic
society. However, it is also true that reducing poverty
is one of the most effective, if not the most effective,
means of promoting the health of the poorer sections
of society, and hence of society at large. We there­
fore hope that everyone, whether or not they work in
the health services, will be able to identify in Part 3
relevant issues, skills and interventions which they can
use and adapt within their own workplace to improve
the health of the people they work with.
Dahlgren G, Whitehead M: Policies and strategies to
promote social equity in health, Stockholm, 1991,
Institute for Future Studies.